Bilateral traumatic C6-C7 facet dislocation with C6 spondyloptosis and large disk sequestration in a neurologically intact patient

Traumatic cervical spondyloptosis is an uncommon and severe form of facet joint dislocation that commonly leads to severe neurological damage. Decision making regarding the reduction and fixation technique is challenging, especially when a patient is neurologically intact, since an undiagnosed prolapsed disk at the involved level may lead to severe neurological consequences during reduction. A 24-year-old male was admitted after sustaining a severe direct axial blow to his head. Computed tomographic and magnetic resonance imaging scans revealed an acute C6C7 fracture dislocation with spondyloptosis of C6 vertebra and a large disk fragment posterior to C6 vertebral body. The patient was neurologically intact, apart from mild bilateral numbness over C6 distribution. The patient underwent C6 corpectomy to avoid acute cord compression related to the large sequestered disk behind C6 vertebra. Following C6 corpectomy, we were unable to exert enough axial pull to reduce the facet dislocation through the anterior approach. Therefore, the reduction was performed through a posterior approach with C5T1 posterior fusion, followed by anterior cage placement and C5-7 anterior fusion (front-back-front approach). At postoperative follow-up of 24 months, the patient demonstrated a full and pain-free cervical range-of-motion and remained neurologically intact. Follow-up radiographs of the cervical spine demonstrated good instrumental alignment with solid fusion at 6-month follow-up.

A new ovine model of spine and chest wall deformity at birth with alteration of respiratory system mechanics and lung development: a feasibility study

PURPOSE

To develop an animal model of spine and chest wall deformity (CWD) at birth and to evaluate its effects on respiratory system mechanics and lung development.

METHODS

A spine and CWD was created in utero between 70 and 75 days of gestation in six ovine fetuses by resection of the seventh and eighth left ribs. Two days after birth, respiratory system mechanics was assessed in anesthetized lambs using the flexiVent apparatus, followed by postmortem measurement of lung mechanics as well as histological lung analysis.

RESULTS

A range of severity of CWD was found (Cobb angle from 0° to 48°) with a mean decrease in compliance of 47% and in inspiratory capacity of 39% compared to control lambs. Proof-of-concept histological analysis in one lamb showed marked lung hypoplasia.

CONCLUSION

Our ovine model represents a pilot proof-of-concept study evaluating the impact of a spine and CWD present at birth on lung respiratory mechanics and development. This study lays down the groundwork for future studies evaluating the impact of these deformities on lung development and potential treatments. These slides can be retrieved under Electronic Supplementary Material.

Anatomical and technical factors associated with superior facet joint violation in lumbar fusion

OBJECTIVE The aim of this study was to evaluate the anatomical and surgical risk factors for screw-related facet joint violation at the superior level in lumbar fusion. METHODS The authors conducted a retrospective review of a consecutive series of posterior lumbar instrumented fusions performed by a single surgeon. Inclusion criteria were primary lumbar fusion of 1 or 2 levels for degenerative disorders. The following variables were analyzed as possible risk factors: surgical technique (percutaneous vs open screw placement), depth of surgical field, degree of anterior slippage of the superior level, pedicle and facet angle, and facet degeneration of the superior level. Postoperative CT scans were evaluated by 2 independent reviewers. Axial, sagittal, and coronal views were reviewed. Pedicle screws were graded as intra-articular if they clearly interposed between the superior and inferior facet joints of the superior level. Multivariate logistic regression analyses were conducted to assess the factors associated with this complication. RESULTS One hundred thirty-one patients were included. Interobserver reliability for facet joint violation assessment was high (κ = 0.789). The incidence of superior facet joint violation was 12.59% per top-level screw (33 of 262 proximal screws). The rate of facet violation was 28.0% in the percutaneous technique group (14 of 50 patients) and 12.3% in the open surgery group (10 of 81 patients) (OR 2.26, 95% CI 1.09-4.21; p = 0.024). In multivariate logistic regression analysis, independent predictors of facet violation were percutaneous screw placement (adjusted OR 3.31, 95% CI 1.42-7.73; p = 0.006), right-side pedicle screw (adjusted OR 3.14, 95% CI 1.29-7.63; p = 0.011), and facet angle > 45° (adjusted OR 10.95, 95% CI 4.64-25.84; p < 0.0001). CONCLUSIONS The incidence of facet joint violation was higher in percutaneous minimally invasive than in open technique for posterior lumbar spine surgery. Also, coronal orientation of the facet joint is a significant risk factor independent of the surgical technique.

The effectiveness of the SpineCor brace for the conservative treatment of adolescent idiopathic scoliosis. Comparison with the Boston brace

BACKGROUND CONTEXT

The Boston brace (Bb) is the most widely used brace design to treat adolescent idiopathic scoliosis (AIS). The dynamic SpineCor (SC) brace is prescribed in several scoliosis clinics worldwide, but its effectiveness remains controversial.

PURPOSE

The study aimed to compare the treatment effectiveness of SC in patients with AIS treated by the developers of the brace with that of the Bb at a single institution.

STUDY DESIGN/SETTING

This is a retrospective comparison between a cohort of AIS patients treated using the SC brace and a cohort treated using the Bb.

PATIENT SAMPLE

We assessed 243 patients treated with either Bb or SC brace to prevent the progression of AIS.

OUTCOME MEASURES

The primary outcome was the progression in main Cobb angle when reaching one of the following end point criteria: (1) progression in Cobb angle of ≥6°, (2) main Cobb angle of ≥45°, (3) surgery undertaken, or (4) reaching skeletal maturity (Risser sign of 5 or growth of <1 cm in the previous 6 months).

METHODS

Patients were identified at a single institution between 2000 and 2012 following the Scoliosis Research Society criteria for brace treatment: (1) diagnosis of AIS, (2) Risser sign of ≤2, (3) curve magnitude between 25° and 40°, and (4) age ≥10 years. A total of 97 patients treated with SC by the developers of the brace and 146 patients treated with Bb were identified. Data collection and radiograph measurements were performed by a single experienced nurse not involved in the decision-making for brace treatment or in the data analysis. Age and Risser sign at onset of treatment, initialmain Cobb angle, curve type, and duration of follow-up were similar in both cohorts. Statistical analysis was done using chi-square and logistic regression models, with a level of significance of .05.

RESULTS

The average progression was 14.7°±11.9° in the SC cohort compared with 9.6°±13.7° in the Bb cohort (p=.003). The average Cobb angle at the end point of the study reached 47°±13° in the SC cohort and 41.7°±14.2° in the Bb cohort (p=.005), whereas at the onset of bracing it was 32.2°±4.9° and 32.2°±4.4°, respectively, for the SC and Bb cohorts. The percentage of patients with a progression of ≥6° was 76% in the SC cohort and 55% in the Bb cohort (p=.001). The proportion of patients reaching 45° in the SC and Bb cohorts was, respectively, 51% and 37% (p=.03), whereas the proportion of patients referred to surgery was 39% and 30%, respectively, for the SC and Bb cohorts (p=.2). The odds of progressing ≥6° and of reaching ≥45° were 2.67 and 2.07 times greater, respectively, when using the SC brace.

CONCLUSIONS

The SC brace did not prevent curve progression as effectively as the Bb. Although it has the potential benefit of increasing mobility during brace wear, the SC brace was associated with increased curve progression in comparison with the Bb. There is also a trend for increased risk of requiring surgery when the SC brace is worn.

Climate gerontology: meeting the challenge of population ageing and climate change

The global population is ageing at a time when climate variability is increasing. It is argued that if we are to minimize the negative impact of environmental change on older people, interdisciplinary study of the convergence of the two trends, "climate gerontology", is needed. Climate gerontology can examine the unique challenges and needs of older people in coping with extreme weather events. It can contribute to our understanding of the everyday challenges of growing old in a changing climate and how we can achieve the "longevity dividend". In particular, it can lead the way to the development of effective policies to reduce the carbon footprint of people during their life course, protect older people from climate-related threats and mobilize their wealth of knowledge and experience to address these.

[Spasmodic left waist pain in a six years old child--cat scratch disease]

Cat scratch disease is caused by Bartonella henselae, a bacterium transmitted to humans from cats through a scratch or by fleas. In 90% of cases, the clinical presentation is that of classical cat scratch disease where an adjacent lymph node is infected. Atypical manifestations include prolonged fever, liver and spleen abscesses, infective endocarditis, central nervous system involvement etc. We present a 6 years old girl who suffered from L2 vertebral osteomyelitis and epidural abscess, initially presenting as colic left waist pain, with no back pain or high fevers. During the process of diagnosis, she recovered without surgical intervention or antibiotic treatment. A review of the literature indicates that among the wide spectrum of clinical manifestations of cat scratch disease, skeletal involvement is rare. However, in cases of osteomyelitis, vertebrae are a common site as well as formation of a contiguous phlegmon. Although no studies have investigated the efficacy of different treatment regimens, all patients presented were treated with antimicrobial combinations and recovery rates were high. In view of the patient presented here, it is questioned whether the high recovery rates are a result of efficient antibiotic treatment or due to a benign natural course of the disease.

Radiological evaluation of intertrochanteric fracture fixation by the proximal femoral nail

BACKGROUND

Successful treatment of intertrochanteric femoral fractures was reportedly influenced by the position of the fixation devices, by reduction quality and by fracture type.

METHODS

The records of 227 patients with intertrochanteric fractures treated by intramedullary hip screws were analysed retrospectively. The angle and distance from the femur head apex were transformed into Cartesian coordinates. Comparisons were performed between patients with no mechanical failure (207 patients, 90.7%), with cutouts (15 patients, 6.6%) and with secondary loss of reduction (5 patients, 2.2%).

RESULTS

The standard tip apex distance (TAD) measurement above 25 mm did not predict failure (p=0.62). Mechanical failure rates increased from 4.8% to 34.4% when the centre of lag screw was not in the second quarter of the head-neck interface line (the so-called "safe zone") (p=0.001). Lag screw insertion lower or higher than 11 mm of the head apex line were associated with failure rates of 5.5% and 18.6%, respectively (p=0.004). Multivariate logistic regression showed that lag screw insertion not within the "safe-zone" was associated an Odds Ratio of 13.4 (95% CI 2.24-81) for mechanical failure (p=0.004).

CONCLUSIONS

The TAD scale focuses on length measurement and lacks the vector properties of multidirectional measurements. Vector analysis revealed that the caudal-cranial correct lag screw position is the most important factor in preventing mechanical failure.

Improved quality of life with hyperbaric oxygen therapy in patients with persistent pelvic radiation-induced toxicity

AIMS

We report the results of hyperbaric oxygen therapy (HBOT) used in the treatment of radiation-induced persistent side-effects after the irradiation of pelvic tumours.

MATERIALS AND METHODS

Between January 2001 and December 2005, 13 women (median age 60.3 years) with radiation combined proctitis/cystitis (n=6), longstanding vaginal ulcers and fistulas (n=5) and longstanding skin injuries (n=2) underwent HBOT in a multiplace chamber for a median of 27 sessions (range 16-40). The treatment schedule was HBOT 100% oxygen, at 2 absolute atmospheres, for 90 min, once a day. For radiation-induced toxicity grading we used the National Cancer Institute Common Toxicity Criteria (CTC) grading system, before and after HBOT.

RESULTS

Thirteen patients underwent an adequate number of HBOT sessions. The mean CTC grading score before HBOT was 3.3+/-0.75, whereas the mean CTC grading score after HBOT was 0.3+/-0.63. The scores showed a significant improvement after HBOT (P=0.001; exact Wilcoxon signed-rank test). Rectal bleeding ceased in five of six patients with proctitis and dysuria resolved in six of seven cystitis patients. Macroscopic haematuria stopped in seven of seven patients. Scar complications resolved in two of two patients. None reported HBOT-associated side-effects.

CONCLUSION

HBOT is apparently safe and effective in managing radiation-induced late side-effects, such as soft tissue necrosis (skin and vagina), cystitis, proctitis and fistulas.

Clinical evaluation of atypical glandular cells of undetermined significance upon cervical cytologic examination in Israeli Jewish women

The adjusted incidence of cervical carcinoma among Israeli Jewish women is ∼5 out of 100 000. This retrospective study sought to determine the clinical implications of finding atypical glandular cells of undetermined significance (AGUS) in cervical cytologic specimens in this population. Cervical cytologic examinations during January 2001–June 2003 diagnosed as AGUS were identified by a computerised database. Medical records were reviewed to determine the presence or absence of associated significant pathologic conditions of the cervix and identified 45 out of 11 800 patients (0.38%) with AGUS. AGUS was the only cytologic diagnosis in 14 patients, while 31 patients had both AGUS and an additional atypical squamous cell of undetermined significance (ASCUS). All subjects underwent colposcopy, endocervical curettage, and cervical biopsy. A clinically significant diagnosis (cervical intraepithelial neoplasia (CIN) II, CIN III, or carcinoma) was made in 24 patients (53.3%), including cancer in three (6.7%): one had microinvasive adenocarcinoma and two had microinvasive squamous cell carcinoma. Squamous carcinoma coexisting with a clinically significant lesion carried a risk of 61.3%, compared with a risk of 35.7% for AGUS alone (P=0.20). Detection of AGUS during cervical cytologic screening, especially with a coexisting ASCUS, indicates the existence of serious pathologic processes; management by cervical colposcopy, endocervical curettage, and cervical biopsy is recommended.

Subclinical thyroid disease in patients with Parkinson's disease

The objective of this study was to determine whether hypothyroidism is more common in Parkinson patients than in a control group without Parkinson, as suggested in the past. We performed a retrospective file review of all admissions to the geriatric ward during a 1-year period. Concentrations of thyroid stimulating hormone (TSH) and thyroxine (T4) from 92 Parkinson patients were compared with those of 225 randomly selected controls from the same ward. Hypothyroidism was not found to be more common in patients with Parkinson disease as previously suggested. Incidentally, we found an unexpected increase in the prevalence of abnormal thyroid laboratory tests in this group. Statistically significant differences were found in two subgroups, (1) men with Parkinson were more likely to have abnormal thyroid laboratory tests as compared with controls; and (2) 'subclinical' hyperthyroidism was found to be more prevalent in Parkinson patients than in controls. Further research in this field is warranted in non-hospitalized patients.

Unanticipated consequences: a comparison of expected and actual retirement timing among older women

The present study adds to the growing body of literature on women and retirement by means of a comparative analysis of the factors associated with anticipated retirement timing (among pre-retirees) and actual retirement timing (among retirees). Adopting a political economy of aging perspective, we argue that socially-structured patterns of gender inequality related to women's multiple roles across the life course affect patterns of retirement timing. Specifically, we hypothesize that the gendered nature of women's work-retirement decision-making is unanticipated during pre-retirement years. Logistic regression analyses are performed on data drawn from a sample of 275 women aged 45 and older living in the Vancouver area of British Columbia. A central finding is that while actual timing of retirement is affected by family caregiving responsibilities and by health/stress factors, pre-retirees do not perceive these to be important in their own expected retirement timing. Implications for social policy, education, and women's financial and psychological well-being in old age are elaborated.

Lack of linkage or association between schizophrenia and the polymorphic trinucleotide repeat within the KCNN3 gene on chromosome 1q21

To determine the importance of a candidate gene KCNN3 (formerly named hSKCa3) in the susceptibility to schizophrenia, we have studied the genotypes of a (CAG)n polymorphism within this gene in the DNAs of the members of 54 multiplex families with this disease. Parametric and nonparametric linkage analysis did not provide evidence for linkage between KCNN3 (that we mapped to chromosome 1q21) and schizophrenia. Furthermore, we observed no difference in the distribution of the (CAG)n alleles between affected and normal individuals. These results do not support the hypothesis that larger KCNN3 alleles are preferentially associated with schizophrenia [Chandy et al. 1998 Mol Psychiatr 3:32-37] in individuals from multiply affected families.

Transmission disequilibrium analysis of a triplet repeat within the hKCa3 gene using family trios with schizophrenia

hKCa3 is a neuronal small conductance calcium-activated potassium channel which contains a polyglutamine tract, encoded by a polymorphic CAG repeat in the gene. Since an association between longer alleles of the CAG repeat and schizophrenia has been reported, we performed haplotype-based haplotype relative risk (HHRR) and transmission disequilibrium (TDT) in 97 family trios with schizophrenia from SW China. We found no evidence for an excess of longer CAG repeats in the patients, and the ETDT test was not significant for either allele-wise (P = 0.31) or genotype-wise analysis (P = 0.18). However, there was a deficit of transmission of the (CAG)20 repeat allele to affected offspring when this allele was considered individually by TDT (P = 0.012; not corrected for multiple testing). These data do not support a role for larger alleles at the hKCa3 locus in psychosis in Chinese subjects.

Reflectance of a wideband multilayer x-ray mirror at normal and grazing incidences

The reflectance of a W-B(4)C multilayer mirror, with a period thickness that increased with depth into the multilayer, was measured at near-normal incidence with synchrotron radiation and at grazing incidence with Cu Kα radiation. The period thickness increased linearly from 17.9 Å at the top of the multilayer structure to 21.9 Å at the substrate while the same ratio of nodal layer to period thickness was maintained. For a grazing angle of 80° (10° from normal incidence), the peak reflectance was 1.1% at a wavelength of 36 Å, and the reflectance profile was 1 Å wide. For Cu Kα radiation the reflectance peaked at a grazing angle of 2.4° and was 0.4° wide. Compared with a W-B(4)C multilayer mirror with a constant period thickness, the depth-graded multilayer mirror has wider reflectance profiles at near-normal and grazing incidences, resulting in larger integrated reflectances and wider fields of view.

High-Performance Mo/Si and W/B4C Multilayer Mirrors for Soft X-Ray Imaging Optics

Soft x-ray projection lithography and microscopy require a high throughput and diffraction-limited performance of a multielement imaging system. To meet these requirements for a specific design it is necessary to (1) achieve high normal incidence reflectivity on each optical element while optimizing the d-spacing variation across the surface of the optical element and (2) match the rf-spacing on each optical element to that of the others according to the ray-tracing design. A technique used to achieve normal incidence reflectivity greater than 60% at 13 nm for Mo/Si and greater than 2.7% at the "water window" region for W/B4C coatings is discussed. In addition, methods to obtain a rf-spacing uniformity of ±0.4% and to match the d-spacing between imaging mirrors with an accuracy of ±0.5% are considered. A method for characterizing multilayer coatings on curved surfaces, using cylindrical witness optics with precalculated shape and radius of curvature to simulate final optics, and a manufacturing method for witness optics are also presented.

Influence of electrical isolation on the structure and reflectivity of multilayer coatings deposited on dielectric substrates

Multilayers prepared with electrically isolated or grounded surfaces during deposition are shown to have dramatically different hard-x-ray, soft-x-ray, and neutron reflectivity characteristics. The effect has been observed for (100) silicon wafers, fused silica, and borate glass substrates of different sizes and with different surface roughness and flatness for multilayer structures prepared by rf and dc magnetron sputtering.

Normal-incidence reflectance of W/B(4) C multilayer mirrors in the 34-50-A wavelength region

The measured normal-incidence reflectances of W/B(4)C multilayers mirrors are 2% in the 34-50-A wavelength region and are consistent with interfacial roughness in the range of 3-4 A.

Forecasting client transitions in British Columbia's Long-Term Care Program

This article presents a model for the annual transitions of clients through various home and facility placements in a long-term care program. The model, an application of Markov chain analysis, is developed, tested, and applied to over 9,000 clients (N = 9,483) in British Columbia's Long Term Care Program (LTC) over the period 1978-1983. Results show that the model gives accurate forecasts of the progress of groups of clients from state to state in the long-term care system from time of admission until eventual death. Statistical methods are used to test the modeling hypothesis that clients' year-over-year transitions occur in constant proportions from state to state within the long-term care system. Tests are carried out by examining actual year-over-year transitions of each year's new admission cohort (1978-1983). Various subsets of the available data are analyzed and, after accounting for clear differences among annual cohorts, the most acceptable model of the actual client transition data occurred when clients were separated into male and female groups, i.e., the transition behavior of each group is describable by a different Markov model. To validate the model, we develop model estimates for the numbers of existing clients in each state of the long-term care system for the period (1981-1983) for which actual data are available. When these estimates are compared with the actual data, total weighted absolute deviations do not exceed 10 percent of actuals. Finally, we use the properties of the Markov chain probability transition matrix and simulation methods to develop three-year forecasts with prediction intervals for the distribution of the existing total clients into each state of the system. The tests, forecasts, and Markov model supplemental information are contained in a mechanized procedure suitable for a microcomputer. The procedure provides a powerful, efficient tool for decision makers planning facilities and services in response to the needs of long-term care clients.

Forecasting demand for long-term care services

This article analyzes three methods used to forecast the transition of long-term care clients through a variety of possible home and facility placements and levels of care. The test population (N = 1,653) is derived from the larger population of clients admitted in 1978 to British Columbia's newly established Long-Term Care program. The investigators have accumulated 5 years of service-generated data on moves, discharges, and deaths of these clients. Results show that the first-order Markov chain with stationary transition probabilities yields a superior forecast to state-by-state moving average growth and state-by-state regression analyses. The results of these analyses indicate that the Markov method should receive serious consideration as a tool for resource planning and allocation in long-term care.